Colorado Violence and Injury PreventionMental Health Promotion Strategic Plan 2016-2020
Creating connected & thriving communities free from violence and injury
Presented by: Violence and Injury Prevention – Mental Health Promotion Branch Prevention Services Division Colorado Department of Public Health and Environment
TABLE OF CONTENTS
I. Forward...........................................................................3 II. Introduction.................................................................. 3 III. The Burden of Injury and Violence in Colorado............4 IV. Critical Target Areas .....................................................8 V. Addressing Priority Shared Risk and
Protective Factors.........................................................10
VI. Evidence-based Strategies Implemented in Colorado.................................................. ....................12 VII. Visual Logic Model ....................................................14 VIII. Violence and Injury Prevention-Mental
Health Promotion Branch Programs........ ....................18
IX. Violence and Injury Prevention-Mental
Health Promotion Branch Strategies........ ...................20
X. Conclusion.............................................. ...................23 XI. Appendix ................................................ ...................24
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 2
FOREWARD Dear Collaborators, Injuries are common, costly and preventable. In Colorado, injury is the leading cause of death for Coloradans ages 1 to 44 years old. Each year, 3,700 Coloradans die from injuries, a loss that affects our communities in lasting ways. The Colorado Department of Public Health and Environment (CDPHE) worked with partners of the Violence and Injury Prevention (VIP) Network to prioritize critical target areas for prevention in Colorado: motor vehicle crashes, interpersonal violence, child maltreatment, traumatic brain injury, suicide, prescription drug overdose, and older adult falls. Colorado’s approaches center around increasing protective factors and reducing risk factors that most impact violence and injury related outcomes at the individual, relationship, community and societal levels. Colorado will implement strategies that increase connectedness (family, school and community), promote positive social norms, support good behavioral health, promote economic stability; and build resilience (individual, familial and community). This plan outlines the innovative, evidence informed strategies that CDPHE and the VIP Network partners are implementing to create connected and thriving communities, free from violence and injury. The CDPHE’s Violence and Injury Prevention--Mental Health Promotion Branch will provide leadership to this work in partnership with stakeholders across multiple sectors, state and local agencies and nonprofits working on violence and injury prevention. Thank you for your collaborative work. Colorado will benefit greatly from your help in implementing this plan.
Larry Wolk, MD, MSPH Chief Medical Officer, Executive Director, Colorado Department of Public Health and Environment
INTRODUCTION The goal of Colorado’s plan is to prevent violence and injury across the state using innovative approaches that are based on the best available evidence. Partners in Colorado work to increase protective factors and reduce risk factors that most impact violence and injury related outcomes at all levels of the social ecology. The socioecological model is a framework for prevention that considers prevention strategies across multiple levels: individual, interpersonal/relationship, organizational, community, and society. Prevention strategies should include a continuum of activities that address multiple levels of the social ecology, as the potential to impact a broader population is greater when implementing prevention strategies at the community and societal levels.
This model also considers the complex interplay between individual, interpersonal, organizational, community, and societal factors and stresses the examination of risk and protective factors within each level. The Violence and Injury Prevention - Mental Health Promotion Branch at CDPHE has been a leader in the field of injury and violence surveillance and prevention since 1989. The branch serves as a model in the development, implementation, and evaluation of innovative, evidence driven, cross-cutting approaches to preventing injury and violence, including integrating community granting and technical assistance with a focus on impacting shared risk and protective factors.
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 3
THE BURDEN OF INJURY & VIOLENCE IN COLORADO Injuries are common, costly, and preventable. In Colorado, injury (including unintentional injuries and violence) is the third leading cause of death, ranking below cancer and heart disease.1 Injury is the leading cause of death for Coloradans ages 1 to 44 years old. Each year, 3,700 Coloradans die from injuries, a loss that affects the individuals, their families and friends, their community and society. In addition to the human toll, injury deaths create a substantial economic burden. In Colorado, injury deaths in 2013 led to over $3.2 billion in combined medical costs and work loss costs.2 However, for every injury death among Coloradans, there are almost 10 injury hospitalizations and 100 emergency department visits. Each year, there are 30,000 hospitalizations and 302,000 emergency department visits for non-fatal injuries among Colorado residents.1 These non-fatal injuries temporarily or permanently disrupt the lives of these individuals.
The outcome of a non-fatal injury can vary from temporary discomfort and inconvenience to chronic pain, disability, and major lifestyle changes. The non-fatal injury hospitalizations in 2013 resulted in an estimated total medical cost of $806,745 and $1.4 billion in work loss costs for a combined total of $2.2 billion in costs. The combined cost of work loss and medical costs totaled $1.7 billion for non-fatal injury emergency department visits. 2 Evidence-informed prevention of injuries works. For example, as the graduated drivers license law in Colorado expanded to encompass effective strategies, the rate of deaths among teen drivers in Colorado declined. This is but one example of the power of societal-level strategies and the usefulness of identifying the causes of injury to inform prevention efforts.
Table1. Leading Causes of Injury among Colorado Residents, 2012-2014 SELECT CAUSES OF INJURY
EMERGENCY DEPARTMENT VISITS
HOSPITALIZATIONS
% TBI
N
107.1
1.9%
7,669
273.5
28.4%
2,883
281,510
1,843.5
19.7%
38,075
24,096
156.8
0.5%
6,982
N
Rate‡
Suicide
16,310
Homicide/Assult
42,370
Rate‡
DEATHS
% TBI
N
Rate‡
% TBI
48.9
2.1%
3,115
19.2
43.3%
18.3
32.1%
563
3.6
31.6%
246.0
18.3%
2,243
14.9
38.9%
42.7
0.9%
1,993
12.3
0.2%
VIOLENCE
UNINTENTIONAL Falls Drug Overdose
†
Motor Vehicle
103,356
664.2
16.2%
10,069
62.6
35.6%
1,450
9.1
35.6%
Struck by/ against
114,119
756.9
19.7%
2,132
13.6
22.9%
44
0.3
0.0%
Natural/ Environmental
41,096
267.2
0.9%
1,852
11.6
5.0%
122
0.8
0.0%
Total Injuries
906,195
5908.5
13.0%
91,969
584.5
17.2%
11,210
70.5
28.9%
Includes undetermined intent Age-adjusted rate per 100,000 population calculated using the direct method and the 2000 U.S. population as the standard Data Sources: Deaths from Colorado Department of Public Health and Environment, Emergency Department Visits and Hospitalizations from the Colorado Hospital Association † ‡
1. Injury in Colorado, 2012-2014. Denver, CO: Colorado Department of Public Health and Environment, 2015.[D41] 2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS): Cost of Injury Reports [online] (2013) [accessed 2016 Feb 12]. Available from URL: www.cdc.gov/injury/wisqars/
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 4
THE BURDEN OF INJURY & VIOLENCE IN COLORADO Leading Causes of Injuries As shown in Table 1, the four leading causes of injury deaths are suicide, falls, unintentional drug overdose (including drug overdoses where intent could not be determined), and motor vehicle events. These four types of injury comprise 79 percent of the injury deaths in Colorado, based on data from 2012 to 2014. Falls, motor vehicle events, unintentional drug overdose (including overdoses with undetermined intent), and unintentionally struck by or against an object or person (such as can occur in sports or in the home) represent 62 percent of the hospitalizations for non-fatal injuries. The leading causes of emergency department visits for non-fatal injuries are falls, unintentionally struck by or against
Violence and Injury Data Injury data used to determine critical target areas can be found under the data tab on www.VIPreventionNetworkCO.com.
an object or person, motor vehicle events, and natural/environmental causes (such as excessive heat or causes involving animals and insects). These four causes contribute to 60 percent of the emergency department visits for non-fatal injury. Unintentional drug overdose is the fifth leading cause of injury-related emergency department visits, accounting for only three percent of the injury visits.
Injury Hospitalization Rates by County of Residence, 2012-2014
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 5
Leading Causes of Injury or V
Colorado Residents, 2 Leading Causes of Injury or Violence-Related Death Colorado Residents, 2012-2014
Age 1-4
de
were sult d
lect
Age 5-9
Age <1
AgeAge 5-9 10-14
Age 1-4 2044 Motor Vehicle Suicide Crashes
19 20 Homicide Motor Vehicle
Crashes 94% were
54 Accidental Suffocation
17 Motor Vehicle
the result
of child 17 Crashes Motor Vehicle abuse 7 Homicide Crashes 3 Drowning 12 Drowning or neglect 14 86% were 3 Other Injury Homicide12 Drowning the result 7 Other Injury 7 Other Injury of child 7 Fires and Burns 93% were7the result abuse Fires and Burns 5 Accidental Suffocation of child abuse or neglect or neglect 5 Accidental Suffocation 3 Accidental Suffocation
Age 35-44
Age 45-54
Age 25-34 656
18 uicide
516 Suicide Suicide
434 Accidental Poisoning
238 Motor Vehicle Crashes 23 Drowning
456 186 Accidental Motor Vehicle Crashes Poisoning
527 Accidental Poisoning
105 Homicide
127 Homicide
75 Other Injury 34 Falls
72 Other Injury
32 Falls 21 Drowning
5 Homicide 40% were the 3 Other Injury result of child abuse or neglect 3 Drowning
3 Accidental Suffocation
Age Age 55-64 45-54
Age 35-44 542
Suicide 656 Suicide
518 Suicide
434 Accidental Poisoning
21
7 Motor Homicide Vehicle Crashes 86% were 9 Other Injury the result of child abuse or neglect
219 Motor Vehicle Crashes 105 Other Injury 83 Falls 79 Homicide
23 Accidental Suffocation
23 Drowning
186 Motor Vehicle Crashes 105 Homicide 75 Other Injury 34 Falls
527356 Accidental Accidental Poisoning Poisoning
202 Motor 219 Vehicle Crashes Motor Vehicle 139 Falls Crashes
105 Other Injury 134
Other Injury 83 Falls 47 Homicide 79 33 Accidental Suffocation Homicide 23 Accidental Suffocation
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 6
Violence-Related Death
Suicide Motor Vehicle Crashes Suicide Homicide Motor Vehicle Crashes Accidental Suffocation Homicide Drowning Accidental Suffocation Falls Drowning FallsAccidental Poisoning
r2012-2014 Violence-Related Death
ts, 2012-2014
y
e
ry
Accidental Poisoning
Age
Age 15-24 15-24
Age Age 10-14
10-14
384
384 Suicide Suicide
44 44 Suicide Suicide
279 279 Motor Vehicle Motor Vehicle Crashes Crashes
2121 Motor Vehicle Motor Vehicle Crashes Crashes 9 Other Injury 9 Other Injury
Homicide 5 Homicide 40% 40%were werethe the result resultofofchild child abuse abuseororneglect neglect 3 Drowning 3 Drowning
205 205 Accidental Poisoning Accidental Poisoning 115 115 Homicide Homicide 49 Other InjuryInjury 49 Other 20 Drowning 20 Drowning 17 Falls
17 Falls
Age 55-64
Age 65+
Age 55-64
Age 65+
542 Suicide
1,938 Falls
542 Suicide
1,938 Falls
356 Accidental Poisoning
356 Accidental Poisoning
202 Motor Vehicle Crashes 202 Falls 139
Motor Vehicle Crashes 134 Other Injury 139 Falls
47 Homicide 33 Accidental Suffocation 134 Other Injury
47 Homicide 33 Accidental Suffocation
455 Suicide
455 Suicide
422 Other Injury 266 422 Motor Vehicle Crashes Injury 191 Other Accidental Suffocation 109 Accidental Poisoning 266 Motor Vehicle Crashes 45 Homicide
191 Accidental Suffocation 109 Accidental Poisoning 45 Homicide
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 7
CRITICAL TARGET AREAS In addition to analyzing the burden of violence and injury as determined by death, hospitalization and emergency department data, the Colorado Department of Public Health and Environment and its partners use the following factors to prioritize critical target areas for prevention and intervention efforts across the state:
5) the existence of, and feasibility of implementing, evidence-based strategies to decrease the burden of violence and injury across the state.
1) existing and potential momentum; 2) political will to prevent violence and injury; 3) the availability of funding and ability to leverage various funding sources to address multiple forms of violence and injury; 4) the priorities and critical target areas set by our state and local partners; and
· Suicide · Prescription drug overdose · Older adult falls · Motor vehicle crashes · Interpersonal violence · Child maltreatment · Traumatic brain injury
Based on these criteria, the following topics are critical target areas for Colorado:
Table 2. Critical Target Areas
SUICIDE
FALLS
PRESCRIPTION DRUG OVERDOSE
MOTOR VEHICLE
CHILD MALTREATMENT
INTERPERSONAL VIOLENCE
TRAUMATIC BRAIN INJURY
Momentum
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Political Will
Gov. Priority Winnable Battle
Winnable Battle
Gov. Priority Winnable Battle
Winnable Battle (state and national)
Yes
Yes, CDPHE Executive Director Support
Brain Injury Alliance advocacy work
Federal: NHTSA & CDC
Federal: SAMHSA, CDC & HRSA
Federal: CDC, RPE, block grant
Federal: SAMHSA, CDC, NHTSA
Existing Federal: Funding Source SAMHSA & CDC
Federal: CDC Federal: & ACL SAMHSA, CDC & BJA
State: CDHS & CDPHE
State: AG, CDHS, MCH & CDPHE
State: CDOT & CDPHE
State: CDHS, MCH & CDPHE
State: CDHS & CDPHE
State: CDHS & CDPHE
State Unit on Aging CO OA Falls Coalition
CDHS Peer Asst. Services Gov’s Office CFPS
CDOT CSP DOR Others CFPS
CDHS Kemp Center Others CFPS
MCH CDHS CCASA CCADV
EfC CFPS CDOT OBH TBI Trust Fund
Yes
Yes
Yes
Yes
Yes
Yes
Partner Priority CDHS Suicide Coalition of CO CFPS Evidence-Based /Informed Strategies Available
Yes
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 8
CRITICAL TARGET AREAS Five-Year Health Outcomes For each of the critical target areas, coalitions were formed to generate outcomes, goals, strategies, and process measures to assess implementation of the related work plans. Below is a list of the health outcome measures that Colorado’s Violence and Injury Prevention Network partners are impacting over the next five years: Suicide: Decrease the overall suicide death, hospitalization and self-reported suicide attempt rate in Colorado. Prescription Drug Overdose: Reduce adult poisoning death and hospitalization rates in Colorado. Falls: Decrease the rate of deaths from older adult falls and hip fractures among adults over age 65 in Colorado. Motor Vehicle Crashes: Reduce the motor vehicle crash hospitalization rate and occupant fatality rate in Colorado.
10 percent reduction Violence and Injury Prevention Network partners established outcome goals of approximately a 10 percent reduction in each of the listed indicators.
Traumatic Brain Injury: By addressing traumatic brain injury (TBI) through the falls, motor vehicle crash, and suicide prevention activities, the state will see a decrease in TBI-related injuries. Colorado Department of Public Health and Environment staff and Violence and Injury Prevention Network partners established outcome goals of approximately a 10 percent reduction in each of the indicators listed on this page. For a detailed outline of the specific objectives and to request information on the updated work plans to address each of these critical target areas, please visit the VIPreventionNetworkCO.com.
Interpersonal Violence: Decrease in percentage of youth experiencing forced sexual intercourse, rates of any teen dating or sexual violence victimization within the past 12 months, and a decrease in emergency department visits due to intimate partner violence. Child Maltreatment: Decrease the rates of children reported to child protective services, emergency department visits coded as child abuse and neglect, inpatient hospitalizations due to child abuse and neglect, deaths of children under age 5 and under due to injury or violence and a decrease in rates of first time victims of child abuse and neglect.
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 9
ADDRESSING PRIORITY SHARED RISK & PROTECTIVE FACTORS
Implementing a shared risk and protective factor approach in Colorado not only has the potential to prevent multiple forms of violence and injury; it also has the potential to leverage resources
•Weak health, educational, economic, and social polices/laws S •Alcohol outlet density C •Access to mental health and substance abuse services C •Substance use I •Poor behavioral control/ impulsiveness I •Witnessing violence and/or history of violent victimization I •Psychological/ mental health problems I
•Societal income inequity S •Weak health, educational, economic, and social polices/laws S •Neighborhood poverty C •Diminished economic opportunities/ high unemployment rates C •Economic stress I/R
Resilience
•Cultural norms that support aggression toward others S •Media violence S •Harmful norms around masculinity and femininity S •Weak health, educational, economic, and social polices/laws S
Good Behavioral Health
•Community violence C •Poor neighborhood support & cohesion C •Coordination of resources and services among community agencies C •Social isolation/ lack of social support I/R •Family conflict I/R •Associating with pro-social peers I/R •Associating with delinquent peers I/R •Connection/ commitment to school I/R •Connection to caring adult I/R •Gang involvement I/R •Low educational achievement I
Social Norms
Connectedness
Risk factors are those characteristics or situations that increase the probability of experiencing injury and/or violence (either as a perpetrator or victim). Protective factors are those characteristics or situations that mitigate the risk of experiencing violence and/or injury, and help to build resilience to thrive when faced with adversity. Risk and protective factors can be attributed
to each level of the social ecology: individuals, families, organizations, communities and societies. Prevention science research suggests that the most effective methods for preventing violence and injury involve addressing both risk and protective factors at each level of the social ecology. Different types of violence and injury share some of the same risk and protective factors. For example, substance abuse is a risk factor for motor vehicle crashes, sexual violence, interpersonal violence, suicide and child maltreatment. A shared risk and protective factor approach involves addressing these shared factors to best impact multiple types of violence and injury outcomes.
Economic Stability
As highlighted previously, injuries and violence are not unique to any specific population or age group. They affect everyone, regardless of age, gender, race or economic status. The outcome of violence and injury can vary from temporary discomfort and inconvenience to chronic pain, disability, major lifestyle changes and death. Violence and injuries not only impact those individuals directly involved, but also families, employers, communities and greater society.
Levels of the social ecology: Societal (S), Community (C), Interpersonal/Relationship (I/R), Individual (I) Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 10
Levels of the social ecology: Societal (S), Community (C), Interpersonal/Relationship (I/R), Individual (I)
•Family conflict I/R •Skills in solving problems nonviolently I •Low educational achievement I •Witnessing violence and/or history of violent victimization I •Poor behavioral control/ impulsiveness I •Lack of nonviolent social problem-solving skills I •Psychological/ mental health problems I
ADDRESSING PRIORITY SHARED RISK & PROTECTIVE FACTORS and partnerships across state and community-based agencies to effectively break down issue-specific silos within agencies and enhance the sustainability of these initiatives. This shared risk and protective factor approach underpins Colorado’s work to reduce the burden of violence and injury across the critical target areas. There is evidence to support the connection between risk and protective factors across the social ecology. This evidence provides the basis for the prioritization of specific risk and protective factors in this plan. Colorado violence and injury prevention stakeholders prioritized common risk and protective factors associated with the state’s critical target areas (noted on page 4). Stakeholders then categorized these factors into five overarching prioritized concepts focused on protective factors: • • • • •
Connectedness (family, school and community) Positive Social Norms Good Behavioral Health Economic Stability Resilience (individual, familial and community)
Each of these larger concepts include specific risk and protective factors across the social ecology. For example, Connectedness encompasses both family connection and support as well as community violence. Positive Social Norms includes harmful norms that support aggression towards others and supportive norms related to gender equity. Community alcohol outlet density and access to mental health and substance abuse services are categorized under Good Behavioral Health. Economic Stability considers high family socioeconomic status and societal income inequality. Lastly, Resilience includes both family and community conflict and individual skills in solving problems non-violently. These are examples of the risk and protective factors as they have been grouped under the broader, strengths-focused concepts, but each of these concepts include more factors than listed here. Though violence and injury prevention partners across the state address shared risk and protective factors within programming, the Colorado Department of Public Health’s Violence and Injury Prevention--Mental Health Promotion Branch will lead work that leverages opportunities and momentum to increase connectedness, positive social norms, good behavioral health, economic stability and resilience. This will be done by coordinating efforts, trainings, technical assistance, and funding. Colorado’s collective state approach is to impact these five prioritized factors at multiple levels of the social ecology.
CONNECTEDNESS
POSITIVE SOCIAL NORMS
GOOD BEHAVIORIAL HEALTH
ECONOMIC STABILITY
RESILIENCE
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 11
EVIDENCE-BASED STRATEGIES IMPLEMENTED IN COLORADO The following tables include a brief overview of some of the evidence-based strategies currently being implemented or funded for implementation in Colorado by statewide partners. This table demonstrates the broad spectrum and existing infrastructure of prevention across the state of Colorado. From primary prevention to intervention, a variety of state and local partners work to address violence and injury shared risk and protective factors across the critical target areas and the social ecology, allowing the state to leverage expertise, funding and resources. Tables 3-9. Critical Target Areas
SUICIDE Evidence Based/Informed Strategies in Colorado
Level of the SEM
• Social norms changes around help-seeking behaviors and reducing stigma • Man Therapy • Hotlines for crisis mental health support
SOCIETAL
• Integrating behavioral health into primary care • Policy changes to improve behavioral health care access and early intervention • Adoption of Zero Suicide in health care systems • ED-CALM COMMUNITY/ • Universal screening to identify depression/ ORGANIZATIONAL suicide risk in health care (this is part of Zero Suicide)
INTERPERSONAL/ RELATIONAL
• Implementing evidence-based health education and social/emotional health curricula or programs, including Sources of Strength, Life Skills Training, QPR Trainings, SOS Signs of Suicide, Mental Health First Aid, Means Restriction (ED-CALM) • • • • •
INDIVIDUAL •
Cognitive Behavioral Therapy Multisystemic Therapy Nurse Family Partnership Mentoring and after-school social-emotional learning programs Minimum training requirements for mental health providers in suicide assessment and management. Implement suicide prevention strategies for first responders
Funding Agencies (See appendix for list of abbreviations)
Connections to other Work
CDPHE, CDHS OBH, AG’s Office, Governor’s Office CDPHE, Anschutz
Child Maltreatment Substance Abuse Interpersonal Violence
CDPHE, CDHS OBH CDE, HCPF, Hospitals, behavioral health, primary care, Commission
Child Maltreatment Substance Abuse Interpersonal Violence
CDHS OBH, TGYS, DCJ, CDE School districts, CDPHE, CO Health Foundation, CDE
Substance Abuse Interpersonal Violence
DCJ, HCPF, CDHS OBH, CDPHE, CDE CDHS, TGYS, OBH Commission, CDPHE
Substance Abuse Child Maltreatment Interpersonal Violence
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 12
EVIDENCE-BASED STRATEGIES IMPLEMENTED IN COLORADO MOTOR VEHICLE CRASHES Level of the SEM
SOCIETAL
COMMUNITY/ ORGANIZATIONAL
INTERPERSONAL/ RELATIONAL
Evidence Based/Informed Strategies in Colorado
Funding Agencies (See appendix for list of abbreviations)
Connections to other Work
• Policies to reduce/prevent impaired driving, including license restrictions, open container bans, high-BAC sanctions, interlocks, social marketing campaigns • Improvement of Colorado’s GDL system by CDOT educating decision makers and parents about best CDPHE practice (esp. min age of permit and curfew) • Social marketing to increase seat belt use among drivers (primary seat belt)
Substance Abuse TBI
• Policies & environments that prevent impaired driving, including SBIRT, responsible beverage service, designated drivers, and increased enforcement of policies CDOT, CDPS NHTSA, CDPHE • Crime Prevention Through Environmental Design (CPTED) to prevent pedestrian injuries • Safe Routes to School and other Community interventions to prevent pedestrian injuries
Substance Abuse TBI
• Education for parents about how to teach their teen to drive and how to enforce graduated drivers licensing at home
CDPHE & CDOT
CHILD MALTREATMENT Level of the SEM
SOCIETAL
COMMUNITY/ ORGANIZATIONAL
INTERPERSONAL/ RELATIONAL
Evidence Based/Informed Strategies in Colorado
Funding Agencies (See appendix for list of abbreviations)
Connections to other Work
• Child maltreatment prevention social marketing campaign to advertise the reporting hotline • Policies that increase minimum wage and universal access to free kindergarten
CDPHE, CDHS, Early Childhood Colorado Partnership
Interpersonal Violence TBI
• Communities that Care • Policies that improve family-friendly businesses, access to childcare and early childhood education, improve social/ emotional health, and more
CDPHE, LPHAs CDHS, Early Childhood Colorado Partnership
Interpersonal Violence Substance Abuse TBI
• Home visitation (NFP, MIECHV, HIPPY, PAT, Healthy Steps, SafeCare) • Positive parenting (Incredible Years Parents)
CDHS Invest In Kids
Interpersonal Violence Substance Abuse Suicide
• Cognitive Behavioral Therapy • Multisystemic Therapy
CDHS
Substance Abuse Suicide
INDIVIDUAL
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 13
EVIDENCE-BASED STRATEGIES IMPLEMENTED IN COLORADO
PRESCRIPTION DRUG OVERDOSE Level of the SEM
Evidence Based/Informed Strategies in Colorado
Funding Agencies (See appendix for list of abbreviations)
• Social marketing campaign to promote safe use, safe storage, and safe disposal of prescription Governor’s Office, CO Consortium drugs and to promote conversations with CDHS OBH adolescents about preventing use
SOCIETAL
• Prescription Drug Monitoring Program (PDMP) • Health Care Provider education about prescribing practices COMMUNITY/ • Evidence-based health education curricula that COMMUNITY/ ORGANIZATIONAL prevents substance abuse ORGANIZATIONAL
DORA, CDPHE, BJA, CO Consortium CDLE, CSPH, CDE, CO Health Foundation, DCJ, CDHS OBH, SAMHSA
• Drug refusal and coping education for families
CDHS OBH, CDE
• SBIRT • Cognitive Behavioral Therapy • Multisystemic Therapy
CDHS OBH, SAMHSA
INTERPERSONAL/ INTERPERSONAL/ RELATIONAL RELATIONAL
INDIVIDUAL INDIVIDUAL
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 14
Connections to other Work Interpersonal Violence TBI Interpersonal Violence Child Maltreatment Suicide Motor Vehicle TBI
EVIDENCE-BASED STRATEGIES IMPLEMENTED IN COLORADO
INTERPERSONAL VIOLENCE Evidence Based/Informed Strategies in Colorado
Level of the SEM
• Comprehensive Sexual Health Policy • Statewide Bullying Prevention Policy enumeration for special populations like LGBT youth
SOCIETAL
COMMUNITY/ ORGANIZATIONAL
INTERPERSONAL/ RELATIONAL
INDIVIDUAL
• Communities that Care • Social norms around healthy relationships • Youth-led community organizing • • • • •
Funding Agencies (See appendix for list of abbreviations)
CDPHE, Colorado Youth Matter CDE
CDPHE, LPHAs, CDHS OBH TGYS
Connections to other Work Interpersonal Violence Suicide Child Maltreatment Substance Abuse Child Maltreatment Interpersonal Violence Suicide
Safe Dates Mentors in Violence Prevention Boys Council Good Behavior Game Positive Behavioral Intervention and Support (PBIS) • Sources of Strength
CDHS OBH, CDE
Interpersonal Violence Substance Abuse Suicide
• Cognitive Behavioral Therapy (specifically for children with sexual behavior problems) • Multisystemic Therapy
Community mental health partners CDHS OBH DCJ
Substance Abuse Child Maltreatment Suicide
TRAUMATIC BRAIN INJURY Evidence Based/Informed Strategies in Colorado
Level of the SEM
• Enhance implementation of Return to Learn/ Play policies
SOCIETAL
Funding Agencies (See appendix for list of abbreviations)
CDPHE, CDE
• Promoting policies and regulations that support CDPHE, CDHS Safe Sleep environments COMMUNITY/ ORGANIZATIONAL
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 15
Connections to other Work Child Maltreatment Interpersonal Violence
Child Maltreatment Interpersonal Violence
EVIDENCE-BASED STRATEGIES IMPLEMENTED IN COLORADO
OLDER ADULT FALLS Evidence Based/Informed Strategies in Colorado
Level of the SEM
SOCIETAL
COMMUNITY/ ORGANIZATIONAL
INTERPERSONAL/ RELATIONAL
INDIVIDUAL
Funding Agencies (See appendix for list of abbreviations)
Connections to other Work
• ACA Wellness Visit billing code to incentivize providers to do falls screening
HCPF
TBI
• Promote health care system policy changes to support older adult falls screening and referrals to classes
CDPHE, LPHAs, COAW
TBI
• Screening for fall risk and referral to evidence based falls prevention programs
Hospitals and primary care physicians
TBI
• • • • •
CDPHE, COAW SUA, Rec Centers, Senior Centers, Hospitals
TBI Suicide
Stepping On Tai Chi:Moving for Better Balance Tai Chi for Arthritis Matter of Balance N’Balance
Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 16
PROTECTIVE FACTORS ADDRESSED BY VIOLENCE AND INJURY PREVENTION-MENTAL HEALTH PROMOTION PROGRAMS The Violence and Injury Prevention--Mental Health Promotion Branch work focuses on strategies that address the shared risk and protective factors that impact the critical target areas of violence and injury in the state: suicide, motor vehicle crashes, falls, prescription drug overdose, sexual violence, and child maltreatment. This work is achieved through data collection and surveillance, implementation of evidence informed programs, policy development, and evaluation activities to measure outcomes. Key to the achievement of these objectives is the development of a violence and injury prevention system throughout Colorado connecting state and local public health and communities by fostering community engagement and building capacity at the local level. O FF PR ICE EV O EN F S TI UIC O ID N * E PR F EV A EN LLS T D PRE ION RU S * G CR O IP VE T RD IO M N O O TO SE R VE CH H VE ILD IC LE N F TI AT * O A N LI IN SYS TY TE TE PR VI RP M* EO ER LE S O ES NC N AL E S CH EN IL TI D AL H S O FO O AB M D R * U J/S SE U B PR S EV TAN M EN EN C PR T TI E O O AL N M H O E TI AL O T N H *
Table 4.0. Shared Risk and Protective Factors Across the Critical Target Areas
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CONNECTEDNESS
POSITIVE SOCIAL NORMS
GOOD BEHAVIORIAL HEALTH
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RESILIENCE
*Impacts TBI Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 17
Creating connected & thriving communities free from violence and injury We are using these resources • • • • • •
Research on effective strategies Data on health issues State & federal funding Existing program resources Experienced staff Strong state and local partnerships • Violence and Injury Prevention Network (including associated state and local coalitions)
to implement these strategies • Strengthen Policies, Systems, Environments • Influence Health Care Systems • Engage Communities • Enhance Surveillance and Evaluation Systems • Communicate Positive Norms Through Various Modalities • Build Capacity for Injury and Violence Prevention at the Local Level
Presented by The Colorado Violence and Injury Prevention Network
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and ultimately reduce to ensure all Coloradans Are connected to: • caring support networks • communities that support healthy and safe behaviors • coordinated resources and services among community agencies
Have positive social norms about: • help-seeking behaviors • making safe and healthy decisions • gender roles • violence and injury prevention being a community responsibility • a picture of health that includes mental health
• Suicide • Older Adult Falls • Prescription Drug Overdose • Motor Vehicle Injuries and Fatalities • Bullying • Sexual Violence • Teen Dating Violence • Intimate Partner Violence • Child Maltreatment • Traumatic Brain Injury
Experience good behavioral health, with: • decreased substance abuse • social and emotional health resources and services • access to mental health and substance abuse services
across their lifespans.
Experience economic stability through: • employment policies that support health, safety and families • increased economic opportunity • improved childcare and school options
Are Resilient, with the skills to: • advocate for personal health care needs/ decisions • solve problems non-violently • rebound after challenging life situations Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 19
VIOLENCE AND INJURY PREVENTION - MENTAL HEALTH PROMOTION BRANCH STRATEGIES As prevention science progresses toward an integrated approach, strategies that tackle shared risk and protective factors in order to impact multiple types of violence and injuries are emerging. Effective programs are based in research and are often applied at the local level, where a multifaceted, evidenced-based program can be tailored and evaluated to meet local needs. However, the most effective prevention programs are not only based in research, but also reflect coordination and collaboration across many types of agencies and organizations. Injury prevention programs are beginning to use structured evaluations to determine which strategies and techniques work best. The concept of “best practices” or “evidence-based” means choosing programs and interventions that are known to be effective based on research and evaluation. Reviews of evidencebased strategies are now available from a number of sources. Evidence-Based Strategies Implemented by Violence and Injury Prevention-Mental Health Promotion Programs In order to impact the outcomes identified as critical target areas, the Violence and Injury Prevention Mental Health Promotion Branch within the Colorado Department of Public Health and Environment is focused on implementing six broad-based strategies. Additional information about the strategies the Violence and Injury Prevention - Mental Health Promotion Branch is implementing is location at VIPreventionNetworkco.com. Sources for the following evidence-based strategies include: the Centers for Disease Control and Prevention’s violence and injury prevention resources and strategies, Safe States’ Injury Prevention Inventory and the Substance Abuse and Mental Health
Services Administration (SAMHSA)’s registries, the National Highway Transportation and Safety Administration (NHTSA), among others. The evidence base used to select these prevention strategies is based on the existing literature on violence and injury prevention, and on shared risk and protective factors (such as Connecting the Dots). The Violence and Injury Prevention Branch is implementing these evidence-based strategies at the community and societal levels of the social ecology in an effort to increase community protective factors and decrease community risk factors, in addition to reducing the burden of violence and injury across the state. Examples of how each strategy is applied to achieve violence and injury prevention objectives are included below:
Strategy 1 Examples: Improve social norms about healthy behaviors • Suicide Prevention: Expand and evaluate a social marketing campaign targeting suicide prevention among working aged males ManTherapy.org Partners in Implementation: Cactus Marketing, Carson J Spencer Foundation, Colorado School of Public Health, University of Maryland at Baltimore, local suicide prevention and behavioral health organizations, state licensee partners, and other stakeholders. • Retail Marijuana Education Program: Educate all Colorado residents and visitors about safe, legal and responsible use of marijuana in a post-legalization world GoodToKnowColorado.com
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VIOLENCE AND INJURY PREVENTION - MENTAL HEALTH PROMOTION BRANCH STRATEGIES Partners in Implementation: Colorado Departments of Revenue, Human Services, Transportation, Education, and Public Safety, the Colorado State Legislature, the Governor’s Office, federal partners, other states, Local Public Health Agencies, and other stakeholders. Strategy 2 Examples: Strengthen policy, systems, & environmental changes • Motor Vehicle Safety: Promote best practice policies known to increase seat belt use and reduce motor vehicle injuries and fatalities. Partners in Implementation: Colorado Department of Transportation, Colorado Department of Human Services, Colorado State Patrol, Colorado Department of Revenue, Colorado AAA, Drive Smart Colorado, Mothers Against Drunk Drivers Colorado, Children’s Hospital Colorado, Colorado School of Public Health • Essentials for Childhood: Promote policy changes that improve family-friendly business practices, increase access to quality and affordable childcare, and improve social emotional health. Policy changes may be formal or organizational. Partners in Implementation: Colorado Department of Human Services, Colorado School of Public Health, Children’s Hospital Colorado, Colorado Early Childhood Councils, Executives Partnering to Invest in Children, Colorado Children’s Campaign, Prevent Child Abuse America Colorado, Early Childhood Comprehensive Systems, Civic Canopy, Mile High United Way, Families First Colorado, Colorado Statewide Parent
Coalition, Kempe Center • Child Fatality Prevention System: Based on data collected on the circumstances of child fatalities, make recommendations to strengthen policies that will prevent future deaths. Examples include strengthening Graduated Driver’s Licensing requirements and passing Primary Seat Belt legislation. Partners in Implementation: Colorado Departments of Human Services, Transportation, and Education, the Colorado State Legislature, federal partners, other states, Local Public Health Agencies, other local child fatality review team members, and other stakeholders Strategy 3 Examples: Build resilience • Interpersonal Violence Prevention: Provide funding for community based agencies across Colorado to implement strategies that impact life skills and resilience. Partners in Implementation: Communitybased agencies, local school districts, Colorado Department of Human Services, Local Public Health Agencies • Suicide Prevention and Interpersonal Violence Prevention: Provide funding to community based agencies and schools to implement Sources of Strength, an evidencebased resilience curriculum in 10 schools across Colorado. Partners in Implementation: Local school districts, local public health, communitybased agencies, the Colorado School Safety Resource Center
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VIOLENCE AND INJURY PREVENTION - MENTAL HEALTH PROMOTION BRANCH STRATEGIES Strategy 4 Examples: Influence health care systems • Suicide Prevention: Pilot implementation of Emergency Department Counseling on Access to Lethal Means (ED-CALM), which trains ED providers to counsel parents or guardians of suicidal youth on the importance of restricting access to firearms and lethal medications in the home. Partners in Implementation: Childrens Hospital Colorado, Colorado School of Public Health, Harvard School of Public Health. • Prescription Drug Overdose Prevention: Increase uptake of evidence-based opioid prescribing guidelines. Partners in Implementation: Colorado Consortium for Prescription Drug Abuse Prevention members, Colorado School of Pharmacy, Colorado Department of Regulatory Agencies, Colorado Department of Human Services, Colorado Department of Health Care, Policy and Financing, Colorado School of Public Health, Colorado Board of Medicine, the Colorado Governor’s Office, the Colorado Attorney General’s Office, Colorado Regional Health Information Exchange, Quality Health Network • Mental Health Promotion: Provide funding to local public health and behavioral health agencies to reduce the stigma of seeking help for behavioral health issues and to increase use of screening tools recommended by the U.S. Preventive Services Task Force for the early identification and intervention of behavioral health problems. Train primary care providers on the behavioral health needs, including screening and referral.
Partners in Implementation: Colorado Departments of Human Services, Health Care Policy and Financing and Regulatory Agencies, Colorado School of Public Health, Colorado Board of Medicine, the Governor’s Office, Local Public Health Agencies, federal partners, other states, and other stakeholders • Older Adult Falls Prevention: Increase the number of health care providers who make successful referrals to evidence-based community fall prevention programs. Partners in Implementation: Colorado Department of Health Care Policy and Financing, Lutheran Family Services, Centura Health System, Consortium for Older Adult Wellness, other clinical practices Strategy 5 Examples: Engage communities • Child Fatality Prevention System: Provide funding for and support local child fatality review teams to make and implement prevention recommendations within their communities based on data regarding local child fatalities. Partners in Implementation: local public health agencies, county human services, local law enforcement agencies, district attorney’s office, school districts, county coroner’s office, medical professionals, mental health professionals, trauma and EMS, child advocates, and other stakeholders. • Retail Marijuana Education Program: Leveraging funding from the Retail Marijuana Tax Cash Fund, CDPHE will fund more than 50 communities in Colorado to implement the Communities That Care (CTC) model, focusing on youth substance abuse prevention outcomes using a shared
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VIOLENCE AND INJURY PREVENTION - MENTAL HEALTH PROMOTION BRANCH STRATEGIES abuse prevention outcomes using a shared risk and protective factor approach. CDPHE will support authentic community engagement and involvement to select and implement community-level policy, systems or environmental change strategies that impact substance use among youth, specifically alcohol and marijuana use and prescription drug misuse. Partners in Implementation: Colorado Departments of Human Services, Education and Public Safety, the Division of Criminal Justice, the Governor’s Office, CU Boulder, Local Public Health Agencies, and other stakeholders Strategy 6 Examples: Enhance surveillance and evaluation systems • Prescription Drug Overdose Prevention: Develop and disseminate guidance on use of Colorado Prescription Drug Monitoring Program (PDMP) data for public health surveillance; improve PDMP infrastructure to support PDMP use as a public health surveillance system; implement strategies that improve linkage of prescription records for each consumer; link PDMP data to health outcomes data, including emergency department, hospitalization, medical record and death certificate data; use PDMP data to identify common characteristics of high-risk groups for opioid misuse by type of payer; and collect, disseminate and analyze county and community level PDMP data and facilitate the use of PDMP data by county and Local Public Health Agencies
of Pharmacy, Colorado Department of Regulatory Agencies, Colorado Department of Human Services, Colorado Department of Health Care, Policy and Financing, Colorado School of Public Health, Colorado Board of Medicine, the Colorado Governor’s Office, the Colorado Attorney General’s Office • Motor Vehicle Safety: Collaborate with state agencies to improve motor vehicle data collection systems and link data sets; assist the data workgroup of the Colorado Task Force on Drunk and Impaired Driving to develop a systematic impaired driving reporting system that will better collect data on driving under the influence of drugs and driving under the influence of alcohol to better understand the issue of impaired driving among teens and adults who transport children. Partners in Implementation: Colorado Department of Transportation, Colorado Department of Human Services, Colorado State Patrol, Colorado Department of Revenue
Partners in Implementation: Colorado Consortium for Prescription Drug Abuse Prevention members, Colorado School Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 23
CONCLUSION Violence and injury exact a large toll on Colorado. Violence and injuries not only affect the individual, but have lasting impacts on families and communities with related economic burdens and lasting trauma. Colorado understands this burden and prioritizes innovative, effective strategies to prevent it. Colorado violence and injury prevention stakeholders are approaching prevention differently. They are breaking down traditional programmatic silos and looking at the factors that protect people, families, and communities from
violence and injury. Research is revealing that risk and protective factors are shared across multiple forms of violence and injury and the time for states to approach their prevention strategies differently is now. Implementing a shared risk and protective factor approach not only has the potential to prevent multiple forms of violence and injury; it also has the potential to leverage limited resources and valuable partnerships. Ultimately, with this plan as a guide, Colorado will create connected and thriving communities, free from violence and injury.
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APPENDIX - COMMON ACRONYMS •
EfC - Essentials for Childhood project funded by CDC
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GDL - Graduated Driver’s Licensing
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HCPF - Colorado Department of Health Care Policy and Financing
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HIPPY - Home Instruction for Parents of Preschool Youngsters
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HRSA - Health Resources and Services Administration
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IV - Interpersonal violence, inclusive of Intimate Partner, Domestic Violence, Sexual Violence, Teen Dating Violence, and Bullying
CDLE - Colorado Department of Labor and Employment, Worker’s Compensation Division
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LPHA - Local Public Health Agencies
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MCH - Maternal Child Health Programs
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CDOR - Colorado Department of Revenue
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CDOT - Colorado Department of Transportation
MIECHV - Maternal, Infant, and Early Childhood Home Visiting
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CDPHE - Colorado Department of Public Health and Environment
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MJ - Marijuana, referring to the Retail Marijuana Education Program
VIP-MHP - Violence and Injury Prevention -
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NFP - Nurse Family Partnership
Mental Health Promotion Branch
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NHTSA - National Highway Transportation Safety Administration
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PAT - Parents as Teachers
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PDMP - Prescription Drup Monitoring Program
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PDO - Prescription Drug Overdose Prevention
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SAMHSA - Substance Abuse and Mental Health Services Administration
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SBIRT - Screening, Brief Intervention and Referral to Treatment
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SIM - The State Innovation Models (SIM) Initiative funded by the Centers for Medicare and Medicaid Services
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ACL - Administration for Community Living
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AG’s Office - Colorado Attorney General’s Office
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BJA - Bureau of Justice Assistance
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CCASA - Colorado Coalition Against Sexual Assault
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CDC - The Centers for Disease Control and Prevention
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CDE - Colorado Department of Education
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CDHS - Colorado Department of Human Services
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OBH - Office of Behavioral Health at CDHS
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TGYS - Tony Grampsas Youth Services at CDHS
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CDPS - Colorado Department of Public Safety •
DCJ - Division of Criminal Justice
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CFPS - Child Fatality Prevention System
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COAW - Consortium for Older Adult Wellness
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CO Consortium - Colorado Consortium for Prescription Drug Abuse Prevention
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Commission - Suicide Prevention Commission
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Core SVIPP - Core State Violence and Injury Prevention Programs funded by the CDC
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CSPH - Colorado School of Public Health
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CTC - Communities that Care
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SPCC - Suicide Prevention Coalition of Colorado
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CU Boulder - University of Colorado at Boulder or Denver
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SUA - State Unit on Aging
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TBI - Traumatic Brain Injury
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DORA - Colorado Department of Regulatory Agencies Colorado Violence and Injury Prevention-Mental Health Promotion Strategic Plan 2016-2020 Page 25